​​           ​NORTHERN LIGHTS CHAPTER  MEMBER APPLICATION​
Please print and mail to Pat Korloch

​​Names - First/Last_________________________________________Date __________         Spouse___________________________________________
FMCA#  _________________   
Address___________________________________________________________________ 
 City/State/Zip____________________________________________________________
Winter Address___________________________________________________________
Phone # Home_________________________________            Cell#1____________________________Cell#2________________________
E-mail Address     #1__________________________#2________________________
Make of Coach__________________Model__________________Length________
His Birthday(Mo/Day)_________Her Birthday(Mo/Day)___________
 Wedding Anniversary  (Mo/Day/Year)  __________________________
Registration Payment
​ 1st year's dues:  $25                                                                            $25                                                               
One Badge:  $20   Two Badges:  $40                                       $_______  
                                                                             Total Enclosed       $________
      Names as you would like them on your badge: ____________________________________  ____________________________________
  Multiple year payments are OK if you'd prefer.   
Yearly Dues: $25 per coach starting second year (October 1 through September 30th)  
All information is Confidential--For Chapter Use Only 
 We will supply a password for our web site personal info​
Make checks payable to:       Northern Lights Chapter, FMCA
Mail to:   Pat Korloch, P.O Box  309, Haslett, MI 48840   
​Email: pk55@juno.com or Phone/ text 517-882-1495
How did you hear about Northern Lights?_________________________________________________
                                                                        Welcome aboard!